What Type of Problems is Bullying Associated With?

Patient Presentation
An 8-year-old male came to clinic for health supervision. His mother said that he seemed to be on the losing end of verbal playground confrontations and was not being included in organized soccer and football games at school. These were games that he loved to play and there had been no problems until the new school year began. The patient was having no other social problems. The pertinent physical exam showed a healthy male with growth parameters in the 10-25% and his examination was normal.

The diagnosis of a healthy male was made. More history showed that a new boy had started school in the fall who was almost a year older and physically larger. The patient stated that the new boy usually picked the teams and decided who would play each recess. The patient and another boy who was also physically smaller were not included very often but were told “you can play in a little while” which didn’t happen by the end of the recess. This occurred before school and during recesses. The patient related that the new boy also was loud in the classroom and lunchroom and would make fun of others, particularly younger children or those that were physically smaller. He would call hiimnames such as “baby” and “twerp.” The new boy would not physically hurt someone but would take advantage of mishaps such as mis-talking or dropping an object to make fun of a person, and when he did so it was quite loud. The patient didn’t feel he could do anything about this. The mother was surprised to hear these details.

The physician and mother agreed that contacting the school counselor to help address the playground and lunchroom relational dynamics would be a good first step. Additionally, the mother thought the counselor could also help her to make the classroom teachers aware of the problem. At followup a few weeks later, the patient reported that he was getting to play with all the kids and do the things he liked to do. The mother reported that counselor and teachers were working with the new boy to give him positive outlets for his leadership abilities (i.e. lunchroom helper) and opportunities to work with smaller children (i.e. reading with first grade students). They also did specific student pairings in academic groups to help the new boy and the other victims learn more about each other as people. On the playground, the teachers reiterated and monitored the school rules that everyone gets a chance to play in activities. The patient said that the new boy was “nicer” now.

Bullying is the use of power and aggression to cause distress or control another person. Bullying is an aggressive behavior conducted from a position of power (which may be obvious or not obvious to others such as size, strength, social status, etc.) and is repeated over time. Although repeated behavior is a key element (and necessarily excludes normal negative interactions such as verbal disagreements), one episode of use of power and aggression is many times seen by children as bullying. Direct bullying is an observable behavior including verbal aggression (e.g. insults, threats, sexual or racial harassment) and physical aggression (e.g. hitting, kicking, punching, etc.) Indirect bullying is sometime called relational aggression and may be unobservable or covert manipulation of social relationships (e.g. rumor spreading, gossiping, exclusion) that hurts or excludes a victim. Cyberbullying is one example of indirect bullying.

Although bullying is seen in all age levels, most people talk about bullying in children and teens.
There are basically 4 groups: children that bully, children that are victims, children that bully and are victims, children that are neither.
A 2009 study in Massachusetts of 5800 middle and high school students (~2900 in each group) found that children who bullied or were bully-victims had higher odds-ratios of being a victim of physical violence and especially of being witness to domestic violence. This increased odds-ratio for domestic violence and bully-victims is especially important as the bully-victims would have the experience of seeing both bully and victim in the domestic violence situation.

Percentage		Neither	Bully		Victim 	Bully-Victim
Middle School		56%		7.5%		26.8%	9.6%
High School		69.5%	8.4%		15.6%	6.5%

Odds Ratios
Middle School
Being physically hurt				--		4.4		2.9		5.0
Witnessing family violence 		--		2.9		2.6		3.9

High School
Being physically hurt				-- 		3.8		2.8		5.4
Witnessing family violence		-- 		2.7		2.3		6.8

After identifying a possible bullying situation, physicians can ask the “5W’s and H” questions to help determine what type of help may be appropriate for an individual situation.

  • Who do you bully/who bullys you?
  • What do you do to others/what do others do to you? (e.g. gossiping, insults, hitting, etc.)
  • When and how often do you bully/are you bullied?
  • Where do you bully/where are you bullied?
  • Why do you bully others/why do you think you are bullied?
  • How do you think the kids feel when you bully them or how do you feel when you are bullied?

Bullying is a multifaceted, relational problem, so multimodal approaches helping individuals, families and the community appear to be the best. Study results appear mixed when looking at the specific types of interventions and their efficacy. School based programs have been evaluated and again their effectiveness is mixed. The CDC recommends: “1) establish a social school environment that promotes safety; 2) provide access to health and mental health services; 3) integrate school, family and community prevention efforts; and 4) provide training to enable [school] staff members to promote safety and prevent violence effectively…. [C]omprehensive strategies that encompass the school, family and community are most likely to be effective.”

Learning Point
Bullying has been associated with poor school/academic achievement, mental health problems, physical health symptoms, substance abuse and other forms of violence. Indicators of children who bully or are victims often are the same including: physical symptoms such as headache or stomachache, difficulty sleeping, enuresis, school problems including absenteeism, dropping out or low grades, drug and alcohol abuse, anxiety and depression and even suicidal thoughts, attempts or completions. Children who bully may also display manipulation and/or aggression towards family members or animals, show little concern for others feelings or posess items/money that are unexplained. Children who are victims may display injuries or have damaged items or clothing. They may need money, be hungry after school or lose items. They may also threaten or carry out injury to themself or others.

Questions for Further Discussion
1. What resources are available in your community for bullying and/or domestic violence?
2. What attributes could be protective against bullying?
3. When does bullying reach the level that the law enforcement needs to be involved?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Bullying

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Mishna F. Learning disabilities and bullying: double jeopardy. J Learn Disabil. 2003 Jul-Aug;36(4):336-47.

MMWR. The Effectiveness of Universal School-Based Programs for the Prevention of Violent and Aggressive Behavior. August 10, 2007. Vol. 56. No. RR-7. Available from the Internet at http://www.cdc.gov/mmwr/pdf/rr/rr5607.pdf (rev. 8/7/2007, cited 3/8/2012).

Vreeman RC, Carroll AE. A systematic review of school-based interventions to prevent bullying. Arch Pediatr Adolesc Med. 2007 Jan;161(1):78-88.

Lamb J, Pepler DJ, Craig W. Approach to bullying and victimization. Can Fam Physician. 2009 Apr;55(4):356-60.

Centers for Disease Control and Prevention (CDC). Bullying among middle school and high school students–Massachusetts, 2009. MMWR . 2011 Apr 22;60(15):465-71. Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6015a1.htm (rev. 4/22/2011, cited 3/8/2012).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.


    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital